| NPI | 1265461875 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: MI 5501006126) |
| Additional Taxonomies | 2255A2300X Specialist/Technologist, Athletic Trainer |
| 2251S0007X Physical Therapist, Sports (Licence: MI L717912) | |
| Enumeration Date | 2006-07-03 |
| Last Update Date | 2022-07-21 |